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Management and Treatment for Cerebral Palsy in Children

Article  in  INDIAN JOURNAL OF PHARMACY PRACTICE · June 2018

DOI: 10.5530/ijopp.11.2.23

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 Case Report

Management and Treatment for Cerebral Palsy in

Children
Padmakar S1*, K Sujan Kumar1, S Parveen2
Pharm-D, P. Rami Reddy Memorial College of Pharmacy [PRRMCP], Kadapa, Andhra Pradesh, INDIA.
1

Department of Pharmacy Assitant Professor, P. Rami Reddy Memorial College of Pharmacy [PRRMCP], Kadapa,
2

Andhra Pradesh, INDIA.

ABSTRACT
‘Cerebral’ – refers to the brain. ‘Palsy’ – can mean weakness or paralysis or lack of muscle control. Therefore,
cerebral palsy is a disorder of muscle control which results from some damage to part of the brain. Cerebral palsy
(CP) is a group of permanent disorders of the development of movement and posture, causing activity limitation,
that are attributed to non-progressive disturbances that occurred in the developing foetal or infant brain. The
motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition,
communication, and behaviour, by epilepsy, and by secondary musculoskeletal problems. Approximately 80% to
90% of children with cerebral palsy have spastic cerebral palsy. The diagnosis of spasticity in children with CP
requires a complete physical examination, with ancillary testing as needed. The aim of treatment is to encourage
the child to learn to be as independent as possible. Some children who have mild cerebral palsy will not have
any problems in achieving independence. For others, it will be a slow process. In some with severe difficulties,
considerable assistance from others will always be needed. Specific treatment varies by individual and changes
as needed if new issues develop. In general, treatment focuses on ways to maintain or improve a person’s quality
of life and overall health. The goal of management of cerebral palsy is not to cure or to achieve normalcy but to
increase functionality, improve capabilities, and sustain health in terms of locomotion, cognitive development,
social interaction, and independence.
Key words: Cerebral palsy, Management, Treatment, Children.

INTRODUCTION
DEFINITION
Cerebral Palsy is a group of permanent, but
not unchanging, disorders of movement
and/or posture and of motor function, which
are due to a non-progressive interference,
lesion, or abnormality of the developing/
immature brain.1
Cerebral palsy is primarily a disorder of
movement and posture. It is defined as an
“umbrella term covering a group of non-
progressive, but often changing, motor
disabilities in poor-resource settings (Glad-
stone, 2010). Not only the prevalence of
childhood disability is on the rise and Cerebral
Palsy is one of the costliest chronic condi- DOI: 10.5530/ijopp.11.2.23
tions, but also life expectancies are improving,
Address for
which increases the burden of Cerebral correspondence:
Palsy (Papavasiliou, 2009). For comparison, in Padmakar S,
the USA, there are approximately 700’000 Pharm.d intership,P. Rami Reddy
Memorial College of Pharmacy
children with Cerebral Palsy, 2-5/ 1000 [PRRMCP], Kadapa, Andhra
born. Pradesh, INDIA.
Phone no: 9603656446
Cerebral Palsy is the most common motor Email Id: spadmakar717@gmail.

impairment syndromes secondary to lesions disability in childhood. The aetiology of com

or anomalies of the brain arising in the early
stages of its development”.2
EPIDEMOLOGY
Unfortunately, it is difficult to access and
clarify the prevalence and incidence rate of
Cerebral Palsy is very diverse and multifac-
torial. The causes are congenital, genetic,
inflammatory, infectious, anoxic, traumatic
and metabolic. Population-based studies
from around the world report prevalence
estimates of Cerebral Palsy ranging from
1.5 to more than 4 per 1,000 live births or www.ijopp.org

104 Indian Journal of Pharmacy Practice, Vol 11, Issue 2, Apr-Jun, 2018
 Padmakar, et al. Management and Treatment of Cerebral palsy in children
children of a defined age range. Most of the children
identified with Cerebral Palsy have Spastic Cerebral
Palsy (77, 4%). Over half of the children identified with
Cerebral Palsy (58, 2%) can walk independently, 11, 3%
walks using a handheld mobility device and 30, 6% has
limited or no walking ability. Many children with Cerebral
Palsy also do have at least one co-occurring condition
(e.g. 41% Epilepsy).3
TYPES OF CEREBRAL PALSY
There are three types of cerebral palsy that can be
distinguished by their symptoms and management
approaches. The man types of CP are Spastic, Ataxic
and Athetoid cerebral palsy.4
A. Spastic Cerebral Palsy: This is the most common
type of CP. Spastic CP is characterized by unique
muscle tightness, patients have muscle spasticity as
the main impairment characteristic.5 This type of CP
occurs in at least 70% of all CP cases in the world.
In cases of spastic CP, the disorder is more easily
manageable as compared to other types since treatment
through medication can be pursued in several neuro­
logical and orthopaedic approaches. The spasticity
of muscles leads to other muscle stress symptoms
that may include tendinitis and arthritis in individuals
who are 20-30 years old. This type of CP can be
managed using occupational and physical therapy
where strengthening, stretching, exercise and other
physical activities are used to manage the disorder
on a daily basis. The disorder can also be managed
using medications that eliminate spasticity by killing
the very nerves that cause the disorder.5
B Ataxic Cerebral Palsy: This type of CP is less common
as compared to spasticity, it may occur in 6-10% of all
cases of CP. Ataxic CP is characterized by “ataxia-type”
symptoms that inflict some cerebellum damage. The
child may exhibit symptoms of unsteady posture.
One may also shake while attempting to hold objects
with the hand. Such symptoms are part of the motor
degraded motor skills experienced by the child. One
may have difficulties in their control of motor skills,
which include typing, writing and holding small
objects. The child may also show some disorientation
and poor control while walking. Visual and auditory
processing may also be affected in ataxic CP.
C Athetoid Cerebral Palsy: This is also called Dyskinetic
CP; it occurs in at least 10% of all CP cases. As
compared to spasticity, the occurrence of this type
of CP is relatively low. Patients with this type of
disorder may have challenges in maintaining steady
positioning. Steady sitting and walking is quite prob-
lematic; individuals may show some unintended
Indian Journal of Pharmacy Practice, Vol 11, Issue 2, Apr-Jun, 2018
Figure 1:  TYPES OF CEREBRAL PLASY
motions. In addition, patients may lose their ability
to hold objects especially small objects that require
some fine or advanced motor control. Such patients
may not be able to hold small objects such as pens,
coins and other small objects.5
CLINICAL RISK FACTORS FOR CP DURING
PREGNANCY
There is increasing scientific evidence that CP is usually
associated with longstanding intrauterine pathology like
genetic mutations and probable environmental triggers
such as bacterial and viral intrauterine infection, intra-
uterine growth restriction (IUGR), antepartum hemor-
rhage, tight nuchal cord, and threatened miscarriage.6 It
can be difficult to pinpoint adverse pregnancy factors
in retrospect, many years after birth, that individually
or together might have triggered the pathways to the
neuropathology.
Preterm delivery
Preterm delivery is a major risk factor for CP and is seen
in approximately 35% of all cases, and the risk increases
the lower the viable gestational age.6,7The risk of sub-
sequent CP <33 weeks’ gestation is 30 times higher
than among those born at term and is approximately
70/1000 deliveries.7 The prevalence of CP is highest in
children born <28 weeks’ gestational age (111.8/1000
neonatal survivors; 82.25/1000 live births) and declines
with increasing gestational age, being 43.15/1000 live
births between 28-31 weeks, 6.75/1000 between 32-36
weeks, and 1.35/1000 for those born >36 weeks.8 The
mechanisms and pathways to the neuropathology of CP
may differ from term babies, although associated risk
factors such as infection, genetic variations, and growth
restriction are likely to contribute.
Coexisting congenital anomalies
The prevalence of congenital anomalies in children
with CP is much higher than in the general population
105
 Padmakar, et al. Management and Treatment of Cerebral palsy in children
and most are cerebral, such as schizencephaly and
hydrocephaly.9 Non-cerebral malformations are also
increased, such as cardiac, musculoskeletal, and urinary.10
In a case-control study of 494 singleton infants with
CP born >35 weeks’ gestation included on the Western
Australian Register of Developmental Anomalies and
508 matched controls, birth defects (42.3%) and fetal
growth restriction (16.5%) were more strongly associated
with CP than potentially asphyxial birth events (8.5%)
and inflammation (4.8%).11 Birth defects had the largest
association with CP in that study in both term and
preterm babies. Growth restricted babies with birth
defects were at special risk of CP. The strong association
with congenital abnormalities suggests possible genetic
factors although congenital infections, nutritional
disorders, and teratogenic influences all contribute to
maldevelopment.
INTRAUTERINE INFECTION
There are many probable antenatal causes of white-
matter damage and risk factors for CP. Some of these
causes include damage acquired following perinatal
infection (i.e., maternal infection that affects the foetus
and its brain during pregnancy and/or labour or in the
neonatal period).12 Viral or bacterial infections may be
relatively silent during pregnancy and not recognized
clinically at the time and the placenta is often discarded
without histological examination for inflammatory
pathology. Maternal reports of fever or infection during
pregnancy are significantly associated with an increased
risk of CP in our recent large Australian case-control
study.13 Evidence of intrauterine infection, evidenced
by histological chorioamnionitis in the placenta and
membranes or intrapartum pyrexia, is associated with
a 4-fold increase in CP (odds ratio 3.8; 95% confidence
interval, 1.5e10.1) in term infants.14
Intrauterine growth restriction
IUGR is associated with up to a 10 to 30 fold increase
in the risk of CP at term.15In particular, spastic CP
increases with the degree of fatal growth restriction.
A growth-restricted foetus may show signs of possible
fatal compromise during labour. This can reflect reduced
capacity/reserves to withstand the normal stresses
of labour, established neurological and ongoing fatal
compromise, or both. It is not possible to distinguish
between these timings.
Multiple pregnancy
Multiple pregnancy increases CP risk 2-fold in each
twin. In vitro fertilization twins each have >4-fold risk
(9.5/1000), giving another reason to encourage single
embryo transfer in fertility programs.16
106
Viral infection in pregnancy
Studies using polymerase chain reaction techniques
on neonatal blood spots from CP cases and controls
show increased CP risk after both Cytomegalovirus and
Epstein-Barr virus infections during pregnancy.17
Epidemiological studies do not associate upper respi-
ratory infections during pregnancy with CP, but some
studies have associated increased risk with bacterial
urinary tract infections.12,18
Genetic causes of CP
Genetic causes have long been suspected because of the
link with congenital malformations, and increased risk
in consanguineous families and monozygotic twins.43
Although initially candidate gene association studies
suggested that several genes may be linked to CP, the
power of these studies was low and multiple comparisons
weakened their validity.19,20
DIAGNOSIS
Observation of slow motor development, abnormal
muscle tone, and unusual posture are common initial
clues to the diagnosis of cerebral palsy. Assessment
of persistent infantile reflexes is important. In infants
who do not have cerebral palsy, the Moro reflex is rarely
present after six months of age, and hand preference
rarely develops earlier than 12 months of age. Hand
preference may occur before 12 months of age if spastic
hemiplegia is present.21 Progressive hereditary neuro-
logic or metabolic disorders must be eliminated as the
cause of observed abnormalities. The testing strategy is
based on the clinical picture, pattern of development of
symptoms, family history, and other factors influencing
the probability of specific diagnoses. Targeted laboratory
tests and cerebral imaging using computed tomography,
magnetic resonance imaging, and ultrasound are useful
physical diagnostic tools. Surveillance for associated
disabilities such as hearing and vision impairment, seizures,
perception problems with touch or pain, and cognitive
dysfunction can help complete the clinical assessment
and determine the diagnosis.22
MANAGEMENT
The goal of management of cerebral palsy is not to
cure or to achieve normalcy but to increase functionality,
improve capabilities, and sustain health in terms of
locomotion, cognitive development, social interaction,
and independence. The best clinical outcomes result
from early, intensive management. Optimal treatment
in children requires a team approach.23 A modern team
approach focuses on total patient development, not
just on improvement of a single symptom. Treatment
Indian Journal of Pharmacy Practice, Vol 11, Issue 2, Apr-Jun, 2018
 Padmakar, et al. Management and Treatment of Cerebral palsy in children
programs encompass physical and behavioural therapy,
pharmacologic and surgical treatments, mechanical aids,
and management of associated medical conditions. In
physical, occupational, speech, and behavioural therapies,
the goals include enhancing patient and caregiver inter-
actions while providing family support.23
Management of spasticity is a major challenge to treatment
team. Various forms of therapy are available to people
living with cerebral palsy as well as caregivers and parents
caring for someone with this disability. They can all be
useful at all stages of this disability and are vital in a CP
person’s ability to function and live more effectively.24
Oral Medications
Oral medications are a systemic, rather than focal, treat-
ment for spasticity in children with cerebral palsy. Oral
medications commonly used in children are baclofen,
diazepam, clonazepam, dantrolene and tizanidine.25
Intrathecal Baclofen
Intrathecal baclofen (ITB) was approved for the treat-
ment of spasticity of cerebral origin in 1996. ITB is a
surgically implanted system used to control spasticity
by infusing baclofen directly into the spinal canal and
around the spinal cord.26Baclofen inhibits spasticity by
blocking excitatory neurotransmitters in the spinal dorsal
horn. ITB maximizes the dose delivered to spinal recep-
tors and minimizes the side effects associated with oral
baclofen.27
Botulinum Toxin
Botulinum toxin (BT) injection is now an established
first-line treatment for focal spasticity. Botulinum toxin
type A produces dose-related weakness of skeletal muscle
by impairing the release of acetylcholine at the neuro­
muscular junction. This partially interrupts muscle
contraction making the muscle temporarily weaker.
Muscles commonly treated with BT include the gastroc-
nemius-soleus complex, hamstrings, hip adductors and
flexor synergy muscles of the upper extremity. Intramus-
cular injections can be localized by surface landmarks,
electromyography stimulation, and/or ultrasound.
Following injection, muscle relaxation is evident within
48 to 72 hr and persists for a period of 3 to 6 months.
Botox injection can help improve a child’s ability to walk
or use hands and allow for a better fitting orthotics by
reducing spasticity. Therapists can take advantage of
the time when an overly powerful muscle is weakened
to work on strengthening the muscle on the opposite
side of the joint (antagonist). Sometimes, casting of the
involved extremity is done after the injection to increase
the stretch of the tight muscle.28-32
Indian Journal of Pharmacy Practice, Vol 11, Issue 2, Apr-Jun, 2018
SURGERY
Orthopedic surgery
Surgery is mainly undertaken on the lower limb, but
occasionally in the upper limb. Some children require
surgery for scoliosis. Physiotherapy is an essential part
of post-operative management. Gait laboratories are
useful in planning the surgical program for children who
can walk independently or with sticks or walking frames.
• The hip: soft tissue surgery is often effective for
children when the hip problems are detected at
an early stage (hence the importance of regular
X-rays). Lengthening of the adductor muscles may
be all that is required in younger children. However,
if the problem progresses, and especially if it is
neglected, more extensive surgery to the hip bones
is required for a significant number of children. For
most children surgery to keep the hips in joint, or
to put the hips back in joint, is preferable to leaving
the child with a dislocated hip which is frequently
painful in later life.
• The knee: lengthening of the hamstrings can help
the knee straighten and so improve the walking
pattern. Sometimes transferring a muscle from
the front to the back of the knee can also help by
reducing stiffness around the knee.
• The ankle and foot: This is the commonest area
where orthopedic surgery is required. Sometimes
children require orthopedic surgery in several different
areas (for example, hip, knee and ankle). Frequently
this now involves a single hospitalization and is
called ‘multilevel surgery’. Multilevel surgery is
of most benefit to children whowalk independently
or with the assistance of crutches.
The best age is usually between 8 and 12 years old
although it can occasionally be helpful for older or
younger children.33
TREATMENT FOR THE ASSOCIATED MEDICAL
PROBLEMS
1. Epilepsy
Knowledge of epilepsy has increased substantially in
the past few years. There are many types of epilepsy,
and medication is often prescribed following a careful
diagnosis of the type of seizures and their cause. The
most commonly used anticonvulsants are: Carbamazepine,
Sodium valproate, Lamotrigine, Phenytoin etc.
2. Saliva control
The speech pathologist plays a central role and can
provide strategies to improve dribbling problems.
When these strategies are not effective, medication is
107
 Padmakar, et al. Management and Treatment of Cerebral palsy in children
occasionally used, particularly in children over the age
of six years. These medications are as follows:
• Benzhexol hydrochloride (‘Artane’) reduces salivary
secretions. Occasionally irritability may occur. Blurring
of vision, constipation and difficulty with urination
are also potential side effects.
• lycopyrrolate (‘Robinul’) is like benzhexol hydro-
chloride but seems to produce fewer side effects.
3. Constipation
Children with cerebral palsy often have problems with
constipation. A high fiber diet and increased fluid intake
can help with this problem. This may not be easily
achieved in some children with cerebral palsy. Careful
use of laxatives is preferable to severe constipation.
4. Nutrition
A dietitian can provide useful advice about adequate
nutrition. Excessive weight gain can be very disadvanta-
geous for children learning to walk. Under nutrition and
failure to make adequate weight gains may be related to
feeding difficulties. In a small proportion of children,
the use of tube feeding can be helpful.33
CONCLUSION
Cerebral palsy is a disorder of muscle control which
results from some damage to part of the brain. Children
with cerebral palsy can have problems such as muscle
weakness, stiffness, awkwardness, slowness, shakiness,
and difficulty with balance which remain throughout the
lifetime of a person. The goal of management of cere-
bral palsy is not to cure or to achieve normalcy but to
increase functionality, improve capabilities, and sustain
health in terms of locomotion, cognitive development,
social interaction, and independence. The management
often requires a variety of different approaches including
oral medications, botulinum toxin, intrathecal baclofen,
occupational and physical therapy and often surgical
interventions.
ACKNOWLEDGEMENT
I acknowledgment the support and help provided by my
guide, parents and my friend.
ABBREVIATIONS
CP-Cerebral palsy; IUGR- intrauterine growth restriction.
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